Otitis Media, Chronic

Key Features

Essentials of Diagnosis

• Chronic otorrhea with or without otalgia

• Tympanic membrane perforation with conductive hearing loss

• Often amenable to surgical correction

General Considerations

• Generally develops as a consequence of recurrent acute otitis media, although it may follow other diseases and trauma

• The bacteriology of chronic otitis media differs from that of acute otitis media; common organisms include

  • Pseudomonas aeruginosa

  • Proteus species

  • Staphylococcus aureus

  • Mixed anaerobic infections

Clinical Findings

• Purulent aural discharge

• Drainage may be continuous or intermittent, with increased severity during upper respiratory tract infection or following water exposure

• Pain is uncommon except during acute exacerbations

Diagnosis

• Conductive hearing loss results from destruction of the tympanic membrane or ossicular chain, or both

• Perforation of the tympanic membrane is usually present; may be accompanied by

  • Mucosal changes, such as polypoid degeneration

  • Granulation tissue and osseous changes, such as osteitis and sclerosis

Treatment

Medication

• Regular removal of infected debris

• Use of earplugs to protect against water exposure

• Topical antibiotic drops (eg, ofoxacin 0.3% or ciprofloxacin with dexamethasone) for exacerbations

• Ciprofloxacin, 500 mg orally twice a day for 1–6 weeks, may help dry a chronically discharging ear

Surgery

• Tympanic membrane repair may be accomplished with temporalis muscle fascia

• Successful reconstruction of the tympanic membrane may be achieved in about 90% of cases, often with elimination of infection and significant improvement in hearing

• When the mastoid air cells are involved by irreversible infection, they should be exenterated at the same time through a mastoidectomy

Outcome

Complications

• Cholesteatoma

  • A special variety of chronic otitis media

  • Most common cause is prolonged eustachian tube dysfunction, with inward migration of the upper flaccid portion of the tympanic membrane

  • Typically erode bone, with early penetration of the mastoid and destruction of the ossicular chain

  • Over time they may erode into the inner ear, involve the facial nerve, and on rare occasions spread intracranially

  • Otoscopic examination may reveal an epitympanic retraction pocket or a marginal tympanic membrane perforation that exudes keratin debris, or granulation tissue

  • Treatment involves surgical marsupialization of the sac or its complete removal

• Petrous apicitis

  • The medial portion of the petrous bone between the inner ear and clivus may become a site of persistent infection when the drainage of its pneumatic cell tracts becomes blocked

  • Foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy (Gradenigo syndrome) may result

  • Meningitis may be a complication

  • Treatment is with prolonged antibiotic therapy (based on culture results) and surgical drainage via petrous apicectomy

• Facial paralysis

  • Usually evolves slowly due to chronic ...